Quality improvement efforts in Quality improvement efforts in Nigerian public health facilitiesNigerian public health facilities

A presentation of FHI Nigeria at the maiden conference of the Society for Quality Healthcare in Nigeria

7 July, 2009

Dr Christoph HamelmannCountry Director

FHI Nigeria program developmentFHI Nigeria program development

Sexual and reproductive health programs (SRH)

HIV/AIDS and SRH

Health systems strengthening and integration of global health initiatives

1988 – 1997 1998 – 2004 2005 – 2007 2008 - 2009

Global Health Initiatives:• HIV/AIDS• TB• SRH• Malaria

Multiple disease programs

Global Health Initiatives (GHI)s

Single disease program

Health systems and integrated GHIs

What Quality Improvement isWhat Quality Improvement is

• Concerted efforts to improve the quality of medical care

• ‘‘… the degree to which health services for individuals and population increases the likelihood of desired health outcomes and are consistent with current professional knowledge’’

— The Institute of Medicine

FHI Quality Assurance Quality FHI Quality Assurance Quality Improvement guiding principlesImprovement guiding principles

Develop standards

Implement standards

Measureperformance

againststandards

Identify quality gaps and performance

issues

Address issues

QA

Identify the improvement

goal/objectives

QIDevelop the

improvement measurement

system

Develop ideas for changes

Test system changes

What aspect of quality improvement What aspect of quality improvement does FHI Nigeria target?does FHI Nigeria target?

FHI specific interventions at public health facilitiesQI Framework • Institute facility-led QI initiatives • Entrench quality improvement culture• Establish Electronic Medical Record (LAMIS)

for longitudinal patients monitoring & management • Establish system-wide leadership for development through

Quality Improvement Project (QIP) team and Multicenter LAMIS Evaluation Group (MLEG)

StructureStructure

• Improve quality of clinical outcomes and public health interventions using evidence-based practices

Outcome Outcome

• Improve systems for delivering quality healthcare services • Enhancing the methods for quality assurance and quality

controls in service delivery • Performance measurements

ProcessProcess

Generic service blueprintGeneric service blueprint

Three good QI examplesThree good QI examples

PMTCTPMTCT

TB/HIVTB/HIV

ARTART

Improvement of case detection of TB/HIV co-infection

Improvement of switching to 2nd line ARVs

Improvement of ARV prophylaxis uptake

Fishbone diagram: rootFishbone diagram: root--causes causes for low ARV prophylaxis uptakefor low ARV prophylaxis uptake

PMTCTPMTCT

Providers

Low ARV prophylaxis uptake

Policy

Resources

Patients

New tool - diariesInadequate staffing

False address

Inadequate information to track patients

Policy issues HW resistance to change

Timing of ARV administration

POS with same day result

Posting, resignationNational Guidelines for commencement of ARV

prophylaxis

Late ordering of drugs

Lack of CD4 machines in stand-alone sites

Cultural beliefs Expensive

High staff turn over

Low hospital delivery rate Transport costs

Domestic violence

Distance

Low rate of return visits to facility

Partner disclosure issues

Stigma

Impact on HIV testing Impact on HIV testing and ARV uptakeand ARV uptake

0

200

400

600

800

1000

1200

Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08

Pregnant women tested HIV positive Pregnant HIV positive woman completed ARV prophylaxis - total

Pre-QI Post-QI

Total number of public health facilities involved in PMTCT QI intervention = 62

PMTCTPMTCT

TB/HIVTB/HIV RootRoot--cause analysis for low case cause analysis for low case detection of TB/HIV codetection of TB/HIV co--infection infection

Personnel

Low detection of TB/HIV co-infection

Policy

Resources

Patients

Inconsistency in the content of counseling provided at

different CT units

Lack of training for lab scientist on use of TB tools

Poor documentation of HCT services at blood bank

Inadequate number of trained staff at blood bank

Wrong referral from blood bank

Lack of HCT providers in the CT unit of Chest Clinic

Poor documentation in TB lab register (patients’ HIV status not documented)

Poor understanding of the National guidelines on TB/HIV collaboration

Poor infrastructure (non-conducive waiting room)

Incessant stock-outs of anti-TB drugs, lab reagents and RTKs

Occasional clients opt out of TB and

HCT services

Inappropriate information to clients referred to TB

lab from main HCT center

Difficulty in locating TB lab

Unavailability of National guidelines and policy documents at sites

Broken-down/non-functional microscopes

TB/HIVTB/HIV Clinical TB screening profile at Clinical TB screening profile at HIV service delivery pointsHIV service delivery points

0%

20%

40%

60%

80%

100%

Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

Proportion of HIV negative clinically screened for TB Proportion of HIV positive clinically screened for TB

QI Intervention begins

Mid Cycle Review & Correction

Impact on TB diagnosis amongst Impact on TB diagnosis amongst HIV positive individualsHIV positive individuals

0%

20%

40%

60%

80%

100%

Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

Proportion of new HIV positive individuals with TB clincal screening score 1+ with 3 AFB sputum smear examinatio

QI Intervention begins Mid Cycle Review & Correction

2 ptmoving

average

TB/HIVTB/HIV

• This chart presents results of TB/HIV QI intervention in 1 pilot site in Nigeria• The key system changes/intervention that led to significant quality improvement is being tested in 42 sites in Nigeria

RootRoot--cause analysis for failure cause analysis for failure to switch to 2nd line ARVsto switch to 2nd line ARVs

ARTART

Providers

Failure to switch to 2nd line drugs

Lab. factors

Resources

Patients

Inadequate information and training of HW on how/when to switch

High staff attrition

Request for investigation not made

Failure to review clients investigation

Recurring CD4 machine breakdown

Late ordering of 2nd line drugs Transport costs

Poor patient monitoring

Low rate of return visits

Restricting sample collection due to manpower shortage

Stock-out of 2nd line drugs

Envisaged 2nd line

drugs toxicityWork overload for physician

Distance from the public health

facilities

Patients not submitting samples for

follow-up investigation

Missed appointments

LTFU

Antiretroviral treatment QI Antiretroviral treatment QI ARTART

Enhanced QA/QI using FHI’s EMR, LAMIS

Automatically generated performance indicators

Multicentre LAMIS Evaluation Group acts as the QA/QI team

ARTART

LAMIS: Performance indicator data LAMIS: Performance indicator data dictionarydictionary

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr

Perc

enta

ges

Proportion of current ART patients who had a Proportion of current ART patients who had a clinical staging done at last clinical visit prior clinical staging done at last clinical visit prior to the reporting date in Massey Street Children to the reporting date in Massey Street Children

hospital, Lagos (N= 663)hospital, Lagos (N= 663)

LAMIS: Scoring system LAMIS: Scoring system

Comparative rankings for facility improvements Comparative rankings for facility improvements on percentage of current ART patients who had a on percentage of current ART patients who had a clinical staging done prior to the reporting date clinical staging done prior to the reporting date

1

0

10

20

30

40

50

60

70

80

90

100

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Perc

enta

ges

Massey Maitama Mainland

123

Facility 1 Facility 2 Facility 3

Conclusions Conclusions

Facility-led QI efforts for public health services supported by TA organization are feasible and

successful in lifting quality of services at public health facilities in Nigeria

Thanks for listening! Thanks for listening!